Paul Tedrick
AHA – Chicago
September 10, 2013
11:00AM CT
Operator:This is a recording of the Paul Tedrick conference with the American Hospital AssociationonSeptember 10th, 2013,at11:00AM Central Time.Ladies and gentlemen, thank you for your patience in holding.We now have your presenters in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of the presentation, we will open the floor for your questions. At that time, instructions will be given as to the procedure to follow if you would like to ask a question. It is now my pleasure to introduce today’s first presenter, Mr. Paul Tedrick.
Paul Tedrick:Good afternoon, everyone. Welcome to the National CAUTI Content Call for September. Today’s topic is Emergency Department and Catheter Insertion. Real briefly, I just wanted to introduce all three of our speakers. Our first speaker is going to be Dr. Mohamad Fakih, and he is – you know what? I’m sorry, I lost my place here. I will come back to Dr. Fakih; I apologize, everyone. So our second speaker is going to be Dr. Lisa Wolf. She is the Director of Research and she is with the Emergency Nurses Association; and another presenter for us today is going to be Dr. Schuur, and I apologize for the delay here. I’m trying to get my – been having some computer issues this morning. Okay, here we go.
So going back to the beginning, our first presenter today is going to be Dr. Mohamad Fakih. He is the Medical Director of Infection Prevention and Control and St. JohnHospital and MedicalCenter in Detroit. He is also a Professor of Medicine at WayneStateUniversity. And presenting after him,we have Lisa Wolf, Dr. Lisa Wolf, and she is with the Emergency Nurses Association. And following Lisa, we have the Chief of the Division of Health Policy at Brigham and Women’s Department of Emergency Medicine; that’s Dr. Jeremiah Schuur. So without further ado, I will go ahead and turn the call over to Dr. Fakih. You may begin.
Dr. Mohamad Fakih:Thank you very much, Paul. Good morning, everyone. Our session objectives are to understand how to improve the compliance with the appropriate indications for urinary cath replacement in the ED for both the nurses and the physicians, and also, I will talk about the improving compliance proper technique for placement and review the points of impact for the emergency nurse in CAUTI prevention, and finally, we’ll review the ED physicians’ role in urinary catheter replacement.
And I’m going to start with a case and it’s the story of Mr. Smith, and Mr. Smith is an 82-year-old gentleman who was admitted to the hospital because of mild congestive heart failure. When he reached the emergency department, he had an urinary catheter placed. Mr. Smith, at that point, was able to use the urinal but they were worried that he may have some trouble walking to the restroom, and they put the catheter in. He was transferred to the floor but he couldn’t sleep, so they gave him sleeping pills. He became more restless, got out of bed and tripped with the catheter and fell, and then he was found to have – at that point, after the fall, he was found to have a left hip fracture and he goes for surgery. Post-operatively, they noted that his leg was swollen and he was diagnosed to have DVT and was started on blood thinners.
So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to remove the catheter because there was no apparent indication for the use, but because of his pain medication, he developed urinary retention. The urinary catheter is placed again and because of the blood thinners, high risk of hematuria – he developed hematuria, the catheter was hard to place and he results in hematuria on blood thinners. A few days later, he developed fever and his blood pressure dropped and blood cultures are done and the urine cultures also; they grew the same organism, Ecoli, and he is diagnosed to have CAUTI and septicemia, and after six weeks in the hospital and many complications, Mr. Smith is no longer the same person who came into the hospital.
Now, you know, some people may see this as exaggeration but for those that have practiced for a long time in a hospital, a similar scenario can be seen, and what I tried to do is I tried to connect the different harms that we may have in the hospital and how they can play together. So one event can lead to multiple other events, and I’m now on the slide – that is slide 6, I think – which shows, you know, the patient’s urinary catheter harm in the center and then you have the infectious issues such as CAUTI, but other issues related to the catheter such as pressure ulcers, immobility. With immobility comes venous thrombo-embolism and falls. Adverse drug events can lead to urinary retention, so the use of the catheter. Patient discomfort is another thing that we rarely discuss. Having a catheter may really bother the patient and they may not feel that, you know, this is something that they should have inside of them. Another item that can be linked to this is length of stay, increased length of stay in the hospital in these patients.
So why are we focusing on the emergency department? When we look at those admitted to the hospital, more than half of those admitted to the hospital get through the emergency department so it’s a great place for us to intervene, to appropriately use the urinary catheter. So the usual decision for placing the catheter often happens in the ED and if we can intervene in the ED and reduce unnecessary placement, we have an impact, not only on the non-intensive care unit but also the intensive care unit. So it’s a global impact on the hospital if we work with the ED.
I’m going to give you some examples from our facility. This is a study we’ve done at my facility, St. JohnHospital and MedicalCenter in Detroit, Michigan, where we looked at 12 weeks of data of those admitted from the emergency department and we looked at those that had a urinary catheter placed, and we checked on the reason why they had the urinary catheter placed. This was after we had an intervention to have institutional guidelines and, you know, clear guidelines for appropriate use for the catheter. What did we find? We found about 12 percent of patients having an urinary catheter placed and about 70 percent of them were indicated, so 30 percent were not fitting the institutional guidelines.
When we looked at those that had the catheter, you know, what was the risks of having a catheter without an appropriate indication? So we found out if the patient was a woman that’s above the age of 80, of those that had a catheter, half of them did not have an appropriate indication, so that group seems to be very vulnerable to inappropriate urinary catheter insertion. Now we know the elderly are very vulnerable to infection and other injury in the hospital. So women were twice as more likely to have a catheter placed inappropriately than men, and the very elderly, whether they’re a woman or a man, were three times more likely than those that are 50 years or younger to have a catheter placed inappropriately.
So what are the common conditions, the conditions where the catheter is placed inappropriately? Elderly, again, are very susceptible to have the catheter placed without an appropriate indication, those that are immobile.Morbid obesity;when you talk to nurses and physicians, sometimes when you ask them, they will place a catheter on someone who’s morbidly obese and it may be a combination of immobility that’s present in that group. Debility of being frail is another one and incontinence is also a factor. Other reasons would be it’s used in non-critically ill cardiac and renal patients, and if you see this, this is pretty much a culture; whether it’s a physician or a nurse practice, it’s usually a local culture in the hospital that’s involved.
So how did we address this at the St. JohnHospital and MedicalCenter? And what we did is we initially worked with the physicians, the emergency physicians, emergency department physicians, and we had consensus from them on institutional guidelines. This was a gravitas effort between myself and an emergency physician, Dr. Pena (ph), who championed the work and was an advocate for appropriate urinary catheter placement (indiscernible 9:39), who did an intervention with minimum – with minimal nursing indication intervention but mostly physician. We had a pre and post-intervention, three months of baseline and then nine months of intervention sustainability. What we found out is that utilization dropped significantly, and when we looked at where did it drop the most, it was dropped in those who had a physician order. So the physician order group improved from having quite a bit of inappropriate indications to less inappropriate indications, and also, the percentage of patients who had a physician order for the catheter had dropped.
What was very interesting is about half of those that had a catheter in the ED at that point did not have a physician order, and when we looked at that proportion of patients post-intervention, they did not have much of a change in their inappropriate use, those that did not have a physician order. So we knew that, at that point, that is not a component that’s extremely important, which is the ED nurse is as important or even more important than the physicians.
I’m on slide 12 right now. I’m going to tell you a little bit about the pilot work. So there are two places where great pilot work has been done. Michigan Hospital Association has led work in about 18, 20 Michigan hospitals, hospital EDs, and Ascension Health had a very small number. In total, more than 30 EDs were involved. What we have done, we engaged both emergency department physicians and nurses, we encouraged establishing institutional guidelines and we looked at change in placement rate and appropriateness. This was done last year, and what we did is we based our appropriate indications on the CDC/HICPAC guidelines to these hospitals, and we allowed them to have additional indications that they thought would be appropriate for the ED.
Now on slide 14. So what was the pilot work? I’m going to show you the pilot work from Ascension Health, 18 EDs in Ascension Health. What we found was, with the intervention, less catheters were placed and in some instances, up to 50 percent drop, average about a third if you look at all the 18 together, and we had them increase the appropriateness of use. The physician order documentation for placement also improved and we had a more noticeable improvement in hospitals who started with a higher baseline. So if the hospital started with a higher baseline of utilization – so let’s they started with 12 percent being placed – they had an improvement, more significant improvement than someone who started with a 6 percent or 5 percent baseline placement. So this is – you know, in the graph bars, as you see the baseline, we had about 9 percent average utilization in all 18 EDs and during the intervention, which was two weeks – the baseline was one week and the intervention two weeks and sustainability was about six months –you’ve seen the drop in utilization from 9 percent, 6 percent and then the sustainability period was less than 6 percent, about 5 percent or something close to that. So great achievement and this would not have been – and as you see also, the appropriate reasons for placement have improved.
So what do we think was key in this case for the improvement? I’m on slide 16. So the first thing is, you know, having clear guidelines on when to use a catheter. I think that’s very important because if we want to talk to a physician or a nurse, we have to have some clarity about when it’s appropriate, when it’s not appropriate to place a full (ph) catheter. The second thing is engaging both stakeholders, the nurses and the physicians, and both have very significant roles in the urinary catheter use; and I think the next two presentations will address each one of them. Lisa?
Dr. Lisa Wolf:Thanks very much. So my name is Lisa Wolf and I am the Director of the Institute for Emergency Nursing Research with the Emergency Nurses Association, and my part of this presentation is to talk to you about some very specific nursing considerations in the emergency department.
So I am going to start on slide number 18, and so the problem essentially is that the emergency department is a very unique setting and so the emergency nurse, at both the initial patient encounter, so when the patient comes in, either through triage or by ambulance, really guides, sets and guides the trajectory of care for these patients, by making clinical decisions that are going to affect patient safety and efficacy and efficiency and also the cost effectiveness of care. And so the role of the emergency nurse is to initially get some sense of what the problem is, how sick the patient is, what kind of resources the patients are going to need and then, finally, to advocate for appropriate care for all these patients who are essentially unknown and potentially really ill. So the role of the emergency nurse is very rooted in an ethical perspective that asks us to do the greatest good for our patients while minimizing harm to them.
I think it’s important to have a sense in the context here is that clinical decision takes place in a social context. We can educate nurses and physicians about when the catheter should go in and when it should come out, but it is the culture of these departments that is going to dictate whether or not the outcome of this clinical decision-making is good for patients or not as good for patients. The attitudes and biases of each participant – nurse, physician, patient, family member – all of these can affect how we express the final expression of this clinical decision-making, and so what’s going to be important is to do a cultural assessment of your department to look at some (audio interference) barriers for implementing culture change. You want to think about who is driving patient care in your department. Is it the nurses? Is it a nurse-driven environment? Is it your physicians? Is it the hospitalists who are admitting your patients into the hospital? Is it the guys in the intensive care unit, your intensivists, intensivist physicians? Or is it the patients and their families themselves who are asking you to put in catheters or to take – or to not put them in? So either one can affect the actual outcome of that decision.
Moving on to the next slide, so we’re on 21 right now, specifically, what is different about emergency department nursing? And I think this is part of the reason that we have partnered with this group in really talking about some important differences in the way that emergency nurses practice than in other areas of the hospital environment. One is that there are very rapidly shifting priorities. We have very sick patients coming in, we have patients who we don’t think are sick coming in who certainly can suddenly become sick. There’s a quick turnover between patients being discharged to home or transferred out to other areas of the hospital. It’s a very chaotic environment. There’s a potential for rapid deterioration. We see people of all ages, you know, babies to the very old, and the most important thing is that we don’t really know what’s wrong with them when they come in necessarily. We have a sense of how they’re responding to whatever’s wrong with them, but we don’t really know. It would be so nice if people came in with little, you know, “hi, I have congestive heart failure,” sort of sign, but they don’t so there is some effort that has to go into the initial diagnosis of what’s going on with a patient.
Because of that, in the emergency department, there is a higher level of autonomous nursing practice than you – than that that may be found in other parts of the hospital. Whereas physicians are the ones who attend to the patient and write orders and make disposition decisions, they are essentially brought to the bedside by the nurse, so the nurse is integral in deciding – you know, assigning acuity, recognizing who is ill, who needs the attention of the physician sooner; and so in this sense, nurses have a really important role in this environment that can’t be discounted in terms of clinical decision-making, especially in the decision to place or not place a catheter. We use a lot of protocols and care guidelines in the emergency department and there is a higher level of collaborative practice, because there has to be because we’re all working together with patients that we’re not really sure what’s wrong with them, again.
So I want to talk a bit about a framework that I use, a practice model that I think is really useful when you’re looking at how to implement CAUTI reduction techniques in your department and how to involve each of the members of the care team and to look overall at how each nurse or each physician is embedded in the culture of your department. So on slide number 23, talk about the framework as an integrated, ethically-driven environmental model. So there are three pieces to this. There are core elements, which are the things that are particular to any given nurse – knowledge base, how much does a nurse know; critical application, how can they apply it to each unique patient situation; and moral agency, which is an ability and a drive to advocate for the patient above all else.